Individual
JENDAYA M CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1201 CYPRESS TER, ROCKFORD, IL 61102-3375
(815) 519-8548
Mailing address
PO BOX 341, ROCKFORD, IL 61105-0341
(815) 519-8548
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
180.012915
IL
Other
Enumeration date
06/23/2020
Last updated
06/23/2020
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